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Faye A. Gary PhD, RN, FAAN

Faye A. Gary PhD, RN, FAAN . Medical Mutual of Ohio Professor for At-Risk and Vulnerable Persons Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio. Purpose of the Presentation. Conceptualize terms: culture, ethnicity, race, disparities

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Faye A. Gary PhD, RN, FAAN

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  1. Faye A. Gary PhD, RN, FAAN Medical Mutual of Ohio Professor for At-Risk and Vulnerable Persons Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio

  2. Purpose of the Presentation • Conceptualize terms: culture, ethnicity, race, disparities • Discuss Cultural Competence • Define key terms • Link disparities and cultural competence • Make Recommendations for Future Action

  3. Basic Assumption • Culture is an important variable in determining how people (consumers, staff & providers) see and interpret (know) the world around them and the basis of how they make decisions.

  4. Power Terms in America • Race: Traditionally thought to refer to a biological phenomenon; it serves to help categorize persons based on some basic physical characteristics such as skin color, the texture of one’s hair, or the shape of one’s eyes, nose, and so forth. • No physiological evidence for categorizing people based on these characteristics. Bushmen in Southern Africa have epicanthic eye folds just as the Asian populations (Owens & King, 1999; Mental Health Report, 2001).

  5. Power Terms When race is used as a social concept, it becomes a forceful and potent phenomenon, determining who gets what goods and services, what groups are considered superior while others bear the burden of being perceived as inferior. Race also helps to determine access to power, and what constitutes high and low status (Clayton and Byrd, 2002).

  6. Power Terms • Ethnicity: Describe common heritages, behaviors, values, perceptions, and folklore of a particular people. Music, language, food preferences, rituals, celebrations, and health beliefs and practices are typically explained with this concept.

  7. Power Terms • Ethnicity: Asian American, can refer to individuals from some 30 or more countries, or Arab Americans could include 15 countries; individuals and families in each of those countries have distinct heritages. • Hispanics are categorized as a particular ethnicity, not a racial group.

  8. Power Terms • Ethnicity: Hispanic ethnicity expands numerous groups, including Cubans, Guatemalans, Mexicans, Puerto Ricans, and others. • Some Hispanics are of African descent, while others are not (Mental Health Report; Schwartz, 2001).

  9. Power Terms • Culture: This concept involves shared meanings among a group of people that are learned ways of thinking and the acquisition of worldviews. Cultural ties extend beyond race and ethnicity, and can include being Southern Baptist, or Catholic, or Muslim, or gay, Hispanic, or a Floridian.

  10. Defining Cultural Competence • Market-Based Definition • Cultural competence is the integration and transformation of knowledge, information, and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual’s culture and increase the quality and appropriateness of health care and outcomes (Davis, 1997).

  11. Defining Cultural Competence • Cultural competence is the conclusion reached and shared by members of a nation, community, group, organization, business, or a board that constitutes how the individual wants to be treated with respect by others based on their culture (T.Davis, 2002)

  12. Who Uses Cultural Competence? • Coca Cola/Pepsi Cola Defense Department • Budweiser Universities • General Motors Hospitals • IBM Managed Health Care • Time Warner Health Departments • HMOs Realtors • Disney Europe Public Schools • Makers of Viagra Religious Organizations

  13. Four Critical Realities • Universities, professional schools, and professional associations are responsible for the level of knowledge, skills, theory, and clinical practice that is applied to people of color. • Cultural competency is not an acceptable approach in the majority of university based education programs. • Most people of color seek help first from religious organizations. • Collaboration/cooperation between religious organizations and behavioral health is minimal. • King Davis, 2003

  14. Elements of Cultural Competence • Attitudes of respect Agency Evaluation • Beliefs Agency Plan • Knowledge and Skills Inclusion in Vision • Language and Communication • Community Analysis Inclusion in Services • Valuing Diversity Outcomes • Cultural Self-Assessment Staffing

  15. Service Issues Related to Cultural Competence • Delays in help seeking • Housing alternatives • Access to trained interpreters • Inclusion in research/clinical trials • Communication between provider/patient, • Integrated behavioral health services

  16. Multiple Costs Associated with Deficits in Cultural Competence • Excess Preventable Deaths • Untreated Illness & Lower Lifetime Achievement • Excess Hospital Admissions & Readmissions • Misdiagnosis & Inappropriate Care • Community Suspicion and Mistrust • Staff Division and Conflict • Absence of Scientific Knowledge & Theory • Ethical Conflict: Professional & Personal • Increased Taxes & Agency Budgets: Waste

  17. Conceptualizing Disparities • Prevalence Rehabilitation • Incidence Participation • Services Outcomes • Treatment Acceptable Norms • Prevention Personal Choice • Recovery Racial causation King Davis, 2003

  18. Service Disparities • Racial, ethnic, and cultural differences in twenty characteristics designed to define and describe the nature of behavioral health service provision • Source: K. Davis (2003)

  19. Barriers to Culturally Competent Health Care • Societal policies: race, gender, income • Focus/content of professional education • Focus /content of research • Service design and implementation • Cultural traditions: beliefs/help seeking • Dissemination of information • Bundling health care to employment

  20. Differences in Health Service Utilization by Ethnicity & Culture • Access to Services/Treatment • Increased Risk Based on Low Income • Help Seeking/Family Participation • Source of Information/Accuracy • Involuntary Admissions/Readmissions • Involvement by Police • Medication Compliance • Severity of Diagnosis/Homelessness

  21. All Health Care is Cultural • Conceptualization • Diagnosis • Treatment • Training • Research • Policy • Help Seeking • Compliance • Participation • Health Beliefs • Expectations • Employment

  22. Why is Cultural Competence Important? • Potential Cost Savings: people & dollars • a. Excess use of inpatient d. >Diagnostic error • b. High rates of recidivism e. >Insurance rates • c. Under-use of outpatient f. LOS • Ethical Base of Professions • Quality of Care Demands it • Potential Improvement in Diagnosis • Potential Improvement in Treatment • Potential for Prevention • Potential for Increasing Participation in Policy • Emphasis on Recovery • Congruent with Evidence Based Approach • Congruent with Disease Management

  23. Need for Behavioral Health Care • African Americans: • Overall rates of mental illness similar to non-Hispanic whites • Differences in prevalence of specific illnesses • Suicide rates lower but on the rise • Environmental, economic and social factors • Exposure to violence, homelessness, incarceration, social welfare involvement • Less access to behavioral health services

  24. Need for Behavioral Health Care • American Indians and Alaska Natives • Limited data on prevalence of MI • One small study with 20 year follow-up found 70% lifetime prevalence of MI • Increase rise of depression among older adults • Suicide rate 1.5xs national average with young males accounting for 2/3 of suicides • 2nd decade of life has highest mortality rate • Alcohol dependence, alcohol related deaths • Little information on service utilization patterns

  25. Need for Behavioral Health Care • Latinos/Hispanic Americans: • Overall rates of MI similar to non-Hispanic whites • Higher rates of some disorders • Anxiety-related and delinquency behaviors, depression and drug use, more common among Latino youth • Higher rates of depression among elderly Latinos • Culture-bound syndromes: • Susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios • Access to behavioral health services is limited

  26. Need for Behavioral Health Care • Asian Americans/Pacific Islanders • Limited data on prevalence of MI • Existing data suggests overall rates similar to whites • Higher rates of depression, PTSD • Somatic complaints of depression • Culture-bound syndromes • Lower suicide rates - except elderly women who have the highest suicide rates in U.S. • Refugees with PTSD • Language barrier limits access to services

  27. American Indian/Alaskan Native Populations by Region. http://www.Indians.org/Resource/FedTribes99/fedtribes99.html

  28. U.S. CensusBureau, Census2000; Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services, p. 55.

  29. U.S.Census Bureau, Census 2000.Mental Health Report, 2000, p. 108.

  30. Census Bureau, Census 2000; Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services, p. 108.

  31. Per Capita Income By Ethnicity in 1999 Per Capita Incomes African Americans $14,397 Asian American $21,134 American Indian Not Available Hispanic American $11,621 White American $24,109 Source: Mental Health Report, 2000, p. 39; U.S. Census Bureau, Current Population Reports, Money Income in the U.S., 1999.

  32. U.S. Census Bureau, 1996, Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050, Current Population Reports, P25-1130, Washington, DC.

  33. General Conclusions • Transformation cannot occur fully without addressing the complex issue of disparities: knowledge, evidence, research, participation, help seeking, etc; • Evidence based approaches must be expanded to include America’s diverse populations; • Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development; • Cultural competence must demonstrate outcome and cost efficacy; • Poverty and related socio-economic issues will affect the application of evidence based approaches; • New epidemiological studies are needed on ethnic minority groups to increase knowledge of help seeking and utilization.

  34. Development of Standards

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